By Melinda Young

Hospitals and subacute facilities monitor congestive heart failure (CHF) patients closely, but there may be a gap in care once patients are discharged.

A transitional heart failure care clinic can fill that gap. A skilled team of professionals oversee patients’ progress in maintaining their medication regimen and adopting healthy habits. The clinic can serve patients after they have transitioned home or to a long-term care facility.

“We have some patients who are in assisted living. Their families will pick up the patient and bring them to the program,” says Elvira Usinowicz, APN, supervisor of the outpatient transitional care unit at The Valley Hospital in Ridgewood, NJ.

This is how The Valley Hospital’s CHF program works:

• Establish the care transition unit. The hospital created the program in the former dialysis unit. It keeps daytime hours for seeing patients in person.

“Basically, we’re inside the hospital, but act as a physician office. We can refer to wherever we want the patient to go,” Usinowicz explains.

The unit’s staff includes Usinowicz as the supervisor, along with registered nurses (RNs), nurse practitioners, office coordinators, and a collaborating physician who specializes in heart failure. The unit also works with an infectious disease physician and can access services advanced cardiac therapies and heart transplant.

“If the patient has a complex wound, we pick up the phone, write a prescription, and the patient goes to the wound department,” she says.

If patients cannot visit the unit, as has happened with some people during the COVID-19 pandemic, the mobile intensive care unit (MICU) can visit the patient at home. The MICU is staffed by a nurse paramedic.

“RN paramedics go into the patient’s home, perform a physical assessment, and then call our nurse practitioners to report the patient’s symptoms,” she explains. “We do phone triage and decide on medications for the patient.”

• Identify CHF patients. The program receives a printout identifying hospitalized patients with a heart failure diagnosis. The algorithm is highly accurate, Usinowicz says.

“If someone gets intravenous Lasix, they’re keyed in,” she adds. “It’s a way of identifying patients before they leave the hospital so we can proactively teach and tell patients that their doctor wants them to come into the program.”

• Visit the patient’s hospital room. The unit’s nursing team visits patients before discharge. “They say, ‘I’m a registered nurse with the outpatient transitional care program. Your doctor would like to ensure you do not come back to the hospital with heart failure symptoms,’” Usinowicz says. “‘I’m going to take the opportunity to teach you some things about your heart failure diagnosis and talk about how we can keep you from returning to the hospital with heart failure.’”

During this first visit, nurses give patients teaching materials. “After introducing myself, I usually begin with providing our heart failure pamphlet and explaining, ‘When your heart is not efficiently pumping for varying reasons, the following might happen…’” explains Erika Bartsch, RN BSN-CHFN, unit nurse with The Valley Hospital.

“I try to approach the patients in a positive manner and engage them in taking charge of their chronic condition,” Bartsch says. “By joining our team, along with their primary cardiologist, other physicians, and family, we can help manage their condition and keep them feeling well and out of the hospital.”

One teaching tool is a guide to CHF zones, which helps patients identify their symptoms and whether they should call a nurse practitioner or go to the hospital. The zones are:

- Green: The patient’s breathing is normal and not experiencing symptoms;

- Yellow: The patient has gained a little weight, is starting to cough, and needs to find out what to do next;

- Red: If the patient is experiencing chest pain, it is time to call 911, Usinowicz explains.

The transitional care unit team created a laminated placemat for patients that includes a heart-healthy food shopping list and a reminder of the best low-sodium foods to select.

Nurses also help patients make appointments to visit the transitional care unit within seven to 14 days after discharge.

• Use tools to improve patient education. “Education is paramount in our program,” Bartsch says. “We are very passionate about educating our patients and their families.”

For instance, on each patient’s first visit, nurses provide CHF binders created by the heart failure RNs. These include sections for patients to keep their personal information, such as doctor’s information, their medication list, their lab tests drawn on that visit, and a daily log for them to chart weight and heart failure symptoms. The binders include information on a low-sodium diet, physical activity, and the heart failure zones diagram, Bartsch adds.

• Connect with patients. “On the initial meeting, the patient needs to put their trust in you as a provider to accept the treatment you’re recommending,” Usinowicz says.

The key is to approach patients in a way that avoids that raised-eyebrow skepticism. “Every patient is approached holistically,” she explains. “We deal with the mind, body, and spirit. We try to make a connection with the patient on some personal level.”

The transitional care unit team gets to know patients’ families and caregivers. Nurses will celebrate patients’ anniversaries and birthdays with balloons and cake.

“Patients become very endeared to us,” she says. “Our approach is to evaluate their learning style and their cognitive ability to retain information, their health literacy, and what kind of family support they have at home.”

The transitional care staff become close to patients. “We are very lucky to work in a program where we have the opportunity to really get to know our patients,” Bartsch says. “This gives us the relationship with them to be their cheerleaders when they are doing well, and their support and guidance when they fall off track.”

Patients can call the transitional care team whenever they run into issues with their weight or new symptoms. “I think they feel very secure that we are there for them if they have setbacks, and this encourages them to stay on top of their disease,” Bartsch says.

• Assess patient at first post-discharge appointment. The patient meets the outpatient transitional care unit team at the first appointment after discharge.

“They are introduced into the purpose of the program, which is to help them manage their heart failure symptoms and to stay well and healthy in the community,” Usinowicz explains. “We take their health history and conduct a physical exam.”

The team also screens patients for depression, using the patient health questionnaire (PHQ-9), and screens for sleep apnea.

“More than 40% of patients with heart failure have some type of sleep disorder with breathing,” she explains.

After drawing blood and conducting the physical exam, the team reviews the patient’s medicines. If needed, nurse practitioners can provide intravenous diuretic therapy and optimize patients’ medications to improve their symptoms. “The goal is to improve the patients’ morbidity and mortality,” Usinowicz says.

Heart failure is a deadly disease with an expected survival of five years or less after diagnosis, she notes. “It’s a progressive, chronic disease,” she says.

While the transitional care program has not collected evidence to show patients receiving this care improve their mortality rate, the data do show improvements in their health outcomes as evidenced by fewer hospital readmissions.

• Repeat visits, as needed. Patients return to the transitional care unit, as needed. It depends on their symptoms.

“We’ll see patients once, twice, three times over a month or a few months,” Usinowicz says. “If they feel very well, then we see them as needed with a referral back to the cardiologist.”

Occasionally, patients are so debilitated and sick the unit team will see them weekly for treatment. “Some patients get tuned up and feel terrific, and we don’t see them again for a few years,” she says. “Some need advanced therapy centers and are on the transplant list.”

Each visit includes the general health assessment, but patients are screened for depression and sleep apnea once a year. “We ask how they’re feeling, weigh them, and perform a physical exam, vital signs, and repeat the blood panel as ordered,” Usinowicz says.

The team reviews the patient’s medications and assesses where patients are in relation to their treatment from a prior visit.

During the COVID-19 pandemic, the unit has offered phone visits for patients when feasible. They follow safe patient guidelines with hand sanitizers, social distancing, and scheduling patients to not be clumped together at the front desk. Patients are permitted to bring one visitor if they need help because of mobility or cognitive issues.

“Some patients are socially isolated, and they come here because we give them so much time, whereas at the physician office it might be a 10-minute visit,” Usinowicz says. “Coming here is a social outing for some patients, and they enjoy it.”